The Benefits of Medical Weight Loss in a Surgical Practice

| December 1, 2020

by Marina S. Kurian, MD, FACS, FASMBS, DABOM, and Flavia Carvalho Silveira, MD

Drs. Kurian and Carvalho Silveira are with New York University Grossman School of Medicine in New York, New York.

FUNDING: No funding was provided.

DISCLOSURES: The authors have no conflicts of interest relevant to the content of this article.

ABSTRACT: Obesity is a chronic disease and a multimodal approach is necessary to maximize weight loss outcomes. This article reviews weight loss medications approved by the United States Food and Drug Administration (FDA) and details how they are incorporated into a surgical practice. Indications for addition of medications are weight regain, insufficient weight loss as well as patients that need preoperative weight management. We provide a quick introduction and strategy to add weight loss medications to your practice to aid in the care of the bariatric patient.

KEYWORDS: weight loss medications, medical weight loss, surgical practice

Bariatric Times. 2020;17(12):10–11

Obesity is a challenging chronic disease that requires continuous management by patients and their doctors. While bariatric surgery is considered a highly effective long-term weight loss solution, not all patients with obesity require that level of treatment.1 Medical weight loss can be the treatment of choice for specific demographics. Patients who are risk-averse, against anatomical changes, or prefer less invasive options might be a great fit for this more conservative approach.

Furthermore, medical weight loss can be a good alternative to surgery for patients where the risk–benefit ratio does not favor surgery. Patients with limited life expectancy, history of drug or alcohol abuse, and untreated severe psychiatric illness are great examples where surgical risk might outweigh its benefits. Another demographic group that can potentially benefit from medical weight loss would be the patients that fail to achieve sustained weight loss following bariatric surgery.

In general, medical weight loss involves the combined use of medications and lifestyle changes, which can result in significant weight loss. This approach has the potential to help patients achieve 5 to 10 percent total body weight loss (TBWL) on average.2 Bariatric surgery can provide much higher success rates and percentage of weight loss, but that comes with the risks and costs associated with the surgery. For patients that do not have health insurance, surgery can cost up to $40,000. Therefore, medical weight loss can be a more affordable treatment when used appropriately.

Many bariatric surgery practices currently include medical weight management as additional therapy for patients. Some studies depict weight regain in 30 to 40 percent of patients after bariatric surgery.3 Large-scale clinical trials have demonstrated that pharmacotherapy can be a good supplemental treatment to improve outcomes for these patients.4 After re-engaging them in a dietary program and assessing individual components, using medications, such as phentermine, can be helpful.5 In large part, this experience is based on the sole availability of phentermine as the one reliable weight loss medication in the past. Currently, there are several medications for weight loss that are approved for chronic use by the United States (US) Food and Drug Administration (FDA).

This increase in the available medications for weight loss represents a great opportunity for doctors and patients looking for tailored treatment. Furthermore, one intervention might not be enough to keep the weight off permanently. As a lifelong chronic disease, obesity is known to have high rates of recurrence; therefore, doctors should employ a diversified approach to maintain weight loss. The development of new medications increased patients’ success rates because they offer help through different mechanisms of actions allowing for personalized care.

Weight Loss Medications

Pharmaceutical companies have developed numerous medications that are specifically directed at weight loss. However, the off-label use of drugs that were not created for weight loss but have known weight loss promoting side effects is not uncommon. The following is a brief overview of some of these medications.

Phentermine is a sympathomimetic and appetite suppressant. Side effects can include jitteriness and insomnia.6 Lomaira™ is a low-dose phentermine given to patients before meals for a direct portion reducing effect. In this low-dose formulation, jitteriness and insomnia might be reduced. Phentermine is FDA-approved for short-term weight loss; however, it has been used for longer duration under the care of a physician. This is considered an acceptable practice by expert opinion and given the safety data from Qsymia™.7

Qsymia™ is a combination of phentermine and topiramate that causes the patient to feel full throughout the day. This is an option for many patients because it helps patients stick to the lifestyle changes prescribed. While taking the medication, patients feel they are not interested in sugary foods or that some of their tastes have changed. Patients are prescribed a diet that is lower in processed carbohydrates as well as meal replacement options.8

Lorcaserin HCL, which used to be sold under the brand name Belviq™, is a different type of medication that targets the 5HT2C receptor, a hunger receptor in the brain. Studies have shown that patients taking BelviqTM could achieve approximately five percent TBWL.9 However, recent data from clinical trials has caused the FDA to request that the manufacturer of Belviq™ voluntarily withdraw the weight-loss drug from the US market. This happened due to safety concerns after clinical trials showed an increased occurrence of cancer from 7.1 percent in controls to 7.7 percent in patients using the medication.10 Therefore, this medication is no longer prescribed.

Contrave™ is a combination of naltrexone, which is an opioid blocker, and bupropion, which is an antidepressant with effects on satiety in some people. Contrave™ seems to be effective as a treatment option for patients who have undergone Roux-en-Y gastric bypass (RYGB) and experienced weight regain. This success is attributed to a reduction in cravings in conjunction with low processed carbohydrate lifestyle recommendations.11

Saxenda™ is a daily injectable glucagon-like peptide 1 (GLP-1) agonist that activates the brain areas that regulate appetite. By regulating one’s appetite, the drug is likely to decrease the number of calories a patient consumes. Saxenda™ helps patients feel full quicker, perhaps by a combination of decreased gastric emptying and better modulation of blood glucose via insulin sensitization of cells. There are other daily and weekly injectable GLP-1 agonists, but they are not FDA approved for weight loss.12

Patients can build tolerance for certain drugs, which causes them to stop losing weight. By combining medications like phentermine and Saxenda™, Contrave™, and Saxenda™, or in the past, Belviq™ and phentermine, physicians can improve the patient’s weight loss trajectory.  Combinations of medications are considered off label but, under the care of a medical doctor, they can be prescribed.

Moreover, in clinical practice it is recommended that drugs are introduced at the lowest dose that is effective. That leaves room to adjust dosing in case the patient’s weight loss plateaus. There are many nuances to weight loss medications alone and in combination. Choosing the best drug for each patient is not always straightforward. This is especially true as we treat postsurgical weight loss patients. In many instances, the weight loss medication we start with is guided by insurance coverage and by the cost of the medication. Trial and error also guide medication choices.

Conclusion

In summary, medical weight management is an effective alternative for treating obesity. It plays an important role in providing support for patients that need to implement lifestyle changes. The different available drugs have distinct mechanisms of actions that have the potential to aid patients in specific areas of their struggle, such as appetite control and cravings. They can also help patients who have undergone bariatric surgery but experience insufficient weight loss or weight regain. Medical weight loss management is the old and yet new way to help these patients start losing weight again.

References

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  8. Qsymia Full Prescribing Information. Campbell, CA: VIVUS, Inc; 2020.
  9. Tronieri JS, Alfaris N, Chao AM, et al. Lorcaserin plus lifestyle modification for weight loss maintenance: Rationale and design for a randomized controlled trial. Contemp Clin Trials. 2017;59:105–112.
  10. Mahase E. Weight loss pill praised as “holy grail” is withdrawn from US market over cancer link. BMJ. 2020:m705.
  11. Onakpoya IJ, Lee JJ, Mahtani KR, et al. Naltrexone-bupropion (Mysimba) in management of obesity: A systematic review and meta-analysis of unpublished clinical study reports. Br J Clin Pharmacol. 2020;86(4):646–667.
  12. Onge E, Miller S, Motycka, C. Liraglutide (Saxenda®) as a treatment for obesity. Food Nutr Sci. 2020;86(4): 646–667.

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